Frequencies and predictors of subcutaneous and intraosseous injection with four epinephrine autoinjector devices

BACKGROUND

To prevent anaphylaxis-associated illness, intramuscular-epinephrine injection is recommended. Subcutaneous injection may reduce efficacy and intraosseous injection promotes morbidity. A few studies suggest that commercially-available thigh-epinephrine autoinjectors (EAIs) may induce subcutaneous/intraosseous injection in some adults.

OBJECTIVE

This cross-sectional study estimated the subcutaneous/intraosseous-injection rates of four EAIs by comparing their needle lengths to the ultrasound-measured skin-to-muscle-depth (STMD) and skin-to-bone-depth (STBD) of the mid-thigh of allergic adults. Patient factors that predict subcutaneous-EAI injection were also determined.

METHODS

Thigh-ultrasound was conducted in a convenience-recruited cohort with minimal and maximal compression to estimate the effect of EAI-induced compression. Subcutaneous/intraosseous-injection rates were estimated for Anapen, EpiPen, Jext, and Emerade. Multivariate analyses for subcutaneous-injection risk were conducted with age, sex, abdominal and thigh circumferences, and upper-arm skinfold thickness.

RESULTS

68 patients were recruited. Compression respectively thinned the subcutaneous tissue and muscle by 1 and 9 mm on average. Projected subcutaneous-injection rates with/without compression were high for Anapen (65-66%), moderate for EpiPen and Jext (29-38%), and lowest for Emerade (13-21%). Compression introduced a small intraosseous-injection risk with Emerade (4%). Female sex predicted subcutaneous injection (Odds-ratios 1.3-2.0, all p<0.001). Depending on the EAI, 29-97% of women and 0-41% of men would be injected subcutaneously. Older men were at risk of intraosseous Emerade injection. Obesity-related variables predicted subcutaneous injection poorly.

CONCLUSION

Anapen associated with high subcutaneous-injection rates. EpiPen and Jext were projected to provide intramuscular injection in all men without risk of intraosseous injection. Emerade yielded the lowest subcutaneous-injection rates in women. Compression largely affected the muscle.

Renal Metastases from a Nasal Cavity Mixed Squamous Cell and Adenoid Cystic Carcinoma: A Case Report

Patient: Female, 64-year-old

Final Diagnosis: Renal metastases from a nasal cavity mixte • squamous cells and adenoid cystic • carcinoma

Symptoms: Epistaxis

Medication: —

Clinical Procedure: —

Specialty: Oncology

A paraneoplastic limbic encephalitis from an anorectal small cell neuroendocrine carcinoma: a case report

BACKGROUND

Paraneoplastic limbic encephalitis (PLE) is a rare autoimmune neurological syndrome observed in cancer patients. PLE is difficult to diagnose and presents a variable response to treatment, depending on the characteristics of the tumor and neuronal autoantibodies.

CASE PRESENTATION

A 64-year-old, Caucasian, non-smoker man presented with a rapidly developing cognitive impairment, personality change, spatial disorientation, and short-term memory loss associated with anorexia and cervical and inguinal lymph nodes. The ¹⁸F-FDG PET scan documented intensely hypermetabolic lymph nodes, which histologically corresponded to a metastasis from a small cell neuroendocrine carcinoma. The brain MRI revealed a high T2-weighted FLAIR signal of the hippocamps, consisted with a PLE. The presence of anti-neuronal Hu antibodies confirmed the diagnosis. The patient underwent plasmapheresis, associated to a systemic chemotherapy resulting in a partial and temporary improvement of the neurological symptoms. Four cycles of intravenous immunoglobulins were also necessary. After six cures of chemotherapy, the lymph node metastases regressed. However, a new anorectal lesion was detected and was histologically confirmed as a primary small cell neuroendocrine carcinoma, which was treated with concomitant chemoradiotherapy. At the end of this treatment, the patient showed a rapid tumor progression leading to his death.

CONCLUSIONS

This case highlights the rare entity, PLE, which is difficult to diagnose and manage. In addition, this is the first published case of PLE associated with an anorectal small cell neuroendocrine carcinoma, which appeared after completion of systemic chemotherapy.

A Subset of Type I Conventional Dendritic Cells Controls Cutaneous Bacterial Infections through VEGFα-Mediated Recruitment of Neutrophils

Skin conventional dendritic cells (cDCs) exist as two distinct subsets, cDC1s and cDC2s, which maintain the balance of immunity to pathogens and tolerance to self and microbiota. Here, we examined the roles of dermal cDC1s and cDC2s during bacterial infection, notably Propionibacterium acnes (P. acnes). cDC1s, but not cDC2s, regulated the magnitude of the immune response to P. acnes in the murine dermis by controlling neutrophil recruitment to the inflamed site and survival and function therein. Single-cell mRNA sequencing revealed that this regulation relied on secretion of the cytokine vascular endothelial growth factor α (VEGF-α) by a minor subset of activated EpCAM+CD59+Ly-6D+ cDC1s. Neutrophil recruitment by dermal cDC1s was also observed during S. aureus, bacillus Calmette-Guérin (BCG), or E. coli infection, as well as in a model of bacterial insult in human skin. Thus, skin cDC1s are essential regulators of the innate response in cutaneous immunity and have roles beyond classical antigen presentation.

Application of the Tissue Composition-Based Model to Minipig for Predicting the Volume of Distribution at Steady State and Dermis-to-Plasma Partition Coefficients of Drugs Used in the Physiologically Based Pharmacokinetics Model in Dermatology

The minipig continues to build a reputation as a viable alternative large animal model to predict humans in dermatology and toxicology studies. Therefore, it is essential to describe and predict the pharmacokinetics in that species to speed up the clinical candidate selection. Essential input parameters in whole-body physiologically based pharmacokinetic models are the tissue-to-plasma partition coefficients and the resulting volume of distribution at steady-state (V_ss). Mechanistic in vitro- and in silico-based models used for predicting these parameters of tissue distribution of drugs refer to the tissue composition-based model (TCM). Robust TCMs were initially developed for some preclinical species (e.g., rat and dog) and human; however, there is currently no model available for the minipig. Therefore, the objective of this present study was to develop a TCM for the minipig and to estimate the corresponding tissue composition data. Drug partitioning into the tissues was predominantly governed by lipid and protein binding effects in addition to drug solubilization and pH gradient effects in the aqueous phase on both sides of the biological membranes; however, some more complex tissue distribution processes such as drug binding to the collagen-laminin material in dermis and a restricted drug partitioning into membranes of tissues for compounds that are amphiphilic and contain sulfur atom(s) were also challenged. The model was validated by predicting V_ss and the dermis-to-plasma partition coefficients (K_p-dermis) of 68 drugs. The prediction of K_p-dermis was extended to humans for comparison with the minipig. The results indicate that the extended TCM provided generally good agreements with observations in the minipig showing that it is also applicable to this preclinical species. In general, up to 86% and 100% of the predicted V_ss values are respectively within 2-fold and 3-fold errors compared to the experimentally determined values, whereas these numbers are 78% and 94% for K_p-dermis when the anticipated outlier compounds are not included. Binding data to dermis are comparable between minipigs and humans. Overall, this study is a first step toward developing a mechanistic TCM for the minipig, with the aim of increasing the use of physiologically based pharmacokinetic models of drugs for that species in addition to rats, dogs, and humans because such models are used in preclinical and clinical transdermal studies.

Peritoneal Myeloid Sarcoma in a Patient Treated for a Testicular Seminoma

BACKGROUND Myeloid sarcoma is a rare extramedullary soft tissue neoplasm composed of myeloblastic cells, usually associated to hematologic tumor disorders and a poor prognosis. Its diagnosis is very difficult as radiological images are not specific. Histology and immunohistochemistry are necessary for an accurate diagnosis. CASE REPORT We report the case of 46-year-old, Caucasian, non-smoker male, treated in 2014 by orchiectomy and systemic chemotherapy for a stage IIB testicular seminoma. Considering the rapid increase of lactate dehydrogenase (LDH) levels without any evident medical reason, a computed tomography/positron emission tomography (CT/PET) scan was performed and revealing a diffuse, nodular, peritoneal tumor infiltration associated with multiple mesenteric and mediastinal adenopathies. Laparoscopy confirmed a diffuse tumor infiltration of the peritoneum. Histology and immunohistochemistry were consisted with the diagnosis of a myeloid monoblastic sarcoma. Cytology of bone marrow documented an monocytic acute myeloid leukemia. The patient started a systemic induction chemotherapy with high dose cytarabine and idarubicin that was complicated by an infectious pneumonia and colitis, and a grade IV thrombocytopenia leading to a brain subdural hemorrhage and quickly to patient's death. CONCLUSIONS We describe a rare, peritoneal, myeloid sarcoma in a young patient who had been treated by systemic chemotherapy for testicular seminoma 4 years earlier. The patient was clinically asymptomatic and presented only elevated LDH levels without any evident clinical reason. Considering the persistence of this biochemical abnormality, more investigations were performed leading to a diagnosis of peritoneal myeloid sarcoma associated with monocytic acute myeloid leukemia, probably secondary to the past chemotherapy.

Breast metastasis from squamous cell carcinoma of the oropharynx: a case report

Background

Breast metastases from extramammary tumors are extremely rare, the most common primary tumors being contralateral breast carcinoma, followed by lung, gynecological, gastrointestinal, melanoma, and hematological cancers. Only a few cases deriving from head and neck squamous cell carcinoma have been reported in the literature to date.

Case presentation

We report a case of a 47-year-old Caucasian woman who presented to our hospital with a solitary breast lesion in the right upper external quadrant associated with multiple bone and visceral metastases. Two years before, she had undergone radical resection of a squamous cell carcinoma of the oropharynx (stage pT2, pN1), which was followed by adjuvant radiotherapy. Breast ultrasound showed a hypoechogenic tumor lesion of 4 cm in the right upper external quadrant that was associated with multiple axillary and infra-/supraclavicular adenopathies. A positron emission tomographic scan documented multiple visceral and bone metastases with a single hypermetabolic lesion of the right breast. The results of histology and immunohistochemistry were consistent with a metastasis from a squamous cell carcinoma. The patient died of acute respiratory insufficiency 1 month after her breast metastasis diagnosis and before starting any systemic antitumoral treatment.

Conclusions

Although breast metastases are extremely rare, they should be considered in any patient with a history of cancer and confirmed by histology and immunohistochemistry because they are very difficult to distinguish from other primary breast tumors based only on clinical and radiological features. There are no standardized treatment guidelines for breast metastasis management. Surgery and radiotherapy can play a role in symptom palliation, but they do not have any relevant impact on survival, the prognosis being poor, with an estimated overall survival less than 1 year from diagnosis.

Pituitary Metastasis from Renal Cell Carcinoma: Description of a Case Report

BACKGROUND Pituitary metastasis is uncommon, breast and lung cancers being the most frequent primary tumors. Renal cell carcinoma (RCC) is a rare cause of pituitary metastases, with only a few cases described to date. CASE REPORT We report a case of a 61-year-old man who presented with a progressive deterioration of visual acuity and field associated with a bitemporal hemianopsia. Two years ago, he underwent radical right nephrectomy for a clear cell RCC (ccRCC). The biological tests showed pan-hypopituitarism and diabetes insipidus. Brain MRI revealed a large sellar tumor lesion bilaterally infiltrating the cavernous sinuses, which was surgically resected. Histology confirmed a ccRCC pituitary metastasis. The patient received post-surgical radiotherapy. Considering the presence of concomitant extra-pituitary metastases, treatment with sunitinib was started, followed by several lines of therapy with axitinib, everolimus, and sorafenib because of tumor progression. The patient also presented with a pituitary tumor recurrence, which was treated by stereotaxic radiotherapy. He died five years after the initial diagnosis of RCC and 30 months after the diagnosis of the pituitary metastasis.  CONCLUSIONS There are no standardized treatment guidelines for management of pituitary metastases. Pituitary surgery plays a role in symptom palliation, and it does not have any relevant impact on survival. Exclusive radiotherapy or stereotaxic radiotherapy could be an alternative to surgery in patients whose general condition is poor or who have concomitant extra-pituitary metastases.

Discovery of AZD2932, a new Quinazoline Ether Inhibitor with high affinity for VEGFR-2 and PDGFR tyrosine kinases

A new series of Quinazoline Ether Inhibitor which potently inhibits VEGFR-2 and PDGFR tyrosine kinases is described here. In vitro, pharmacokinetics and in vivo evaluations led to the selection of AZD2932.

Efficient three-step one-pot synthesis of a novel 2,3,5-substituted pyrazine library

The partnership between rational synthesis design and mass-triggered preparative LCMS is a powerful one, capable of furnishing very large libraries in a selective manner in a very short space of time. Herein, we communicate one example of possibly a perfect marriage between the synthetic chemistry and the subsequent purification method employed, affording a ∼1000-member library supplying 50 mg on average of final compound in less than a month.

Embolisation of Symptomatic Pelvic Veins in Women Presenting with Non-saphenous Varicose Veins of Pelvic Origin – Three-year Follow-up

AIM

To evaluate the clinical results of embolisation of symptomatic, incompetent pelvic veins in women presenting with perineal veins.

PATIENTS AND METHODS

Twenty-four women presenting with non-saphenous perineal varicose veins and who experienced pelvic vein syndrome were treated. Symptoms was scored on a visual analogue scale assessing dyspareunia, pelvic and lower limb pain. Lower limb varices were investigated by duplex ultrasonography. Pelvic veins were studied by pelvic vein angiography with simultaneous embolisation of incompetent veins. Ovarian and internal iliac veins were systematically embolised when incompetent. Follow-up assessment of symptoms and varices was carried out at 1, 2 and 3 years.

RESULTS

All patients presented with perineal veins, 2 with sciatic vein incompetence and 2 with a perforator of the thigh or buttock. Pelvic venous angiography was performed via right femoral access in 87% of the cases and confirmed the presence of incompetent ovarian and internal iliac veins. The mean number of coils used per vein was 6 and all were successfully embolised. No serious complications were encountered. The mean clinical improvement score was 80%, 77%, 80% and 76% at respectively 45 days, 1, 2 and 3-year follow-up.

CONCLUSION

In women of reproductive age, non-saphenous varicose veins associated with pelvic venous incompetence (PVI) should undergo pelvic vein investigation. In this clinical series we achieved a satisfactory improvement in symptoms after 3 years following treatment of incompetent pelvic veins.

New heterocyclic analogues of 4-(2-chloro-5-methoxyanilino)quinazolines as potent and selective c-Src kinase inhibitors

A series of 5,7-disubstituted quinazolines, bearing 4-heteroaryl substituents such as 2-pyridinylamine or 2-pyrazinylamine, has been synthetised and evaluated as c-Src kinase inhibitors. Highly potent inhibition, high selectivity and physical properties suitable for oral dosing were achieved within this series: 23d and 42 were identified as sub-0.1muM inhibitors in a c-Src-driven cell proliferation assay and displayed adequate rat pharmacokinetics after oral administration.

Complete structure of an increasing capillary permeability protein (ICPP) purified from Vipera lebetina venom. ICPP is angiogenic via vascular endothelial growth factor receptor signalling

The partial sequence of the increasing capillary permeability protein (ICPP) purified from Vipera lebetina venom revealed a strong homology to vascular endothelial growth factor (VEGF)-A. We now report its complete amino acid sequence determined by Edman degradation and its biological effects on mouse and human vascular endothelial cells. ICPP is a homodimeric protein linked by cysteine disulfide bonds of 25115 Da revealed by mass spectrometry. Each monomer is composed of 110 amino acids including eight cysteine residues and a pyroglutamic acid at the N-terminal extremity. ICPP shares 52% sequence identity with human VEGF but lacks the heparin binding domain and Asn glycosylation site. Besides its strong capillary permeability activity, ICPP was found to be a potent in vitro angiogenic factor when added to mouse embryonic stem cells or human umbilical vein endothelial cells. ICPP was found to be as potent as human VEGF165 in activating p42/p44 MAPK, in reinitiation of DNA synthesis in human umbilical vein endothelial cells, and in promoting in vitro angiogenesis of mouse embryonic stem cells. All these biological actions, including capillary permeability in mice, were fully inhibited by 1 microm of a new specific VEGF receptor tyrosine kinase inhibitor (ZM317450) from AstraZeneca that belongs to the anilinocinnoline family of compounds. Indeed, up to a 30 times higher concentration of inhibitor did not affect platelet-derived growth factor, epidermal growth factor, FGF-2, insulin, alpha-thrombin, or fetal calf serum-induced p42/p44 MAPK and reinitiation of DNA synthesis. Therefore, we conclude that this venom-derived ICPP exerts its biological action (permeability and angiogenesis) through activation of VEGF receptor signaling (VEGF-R2 and possibly VEGF-R1).

[Prognostic factors of Pneumocystis carinii pneumonia in AIDS]

OBJECTIVES

Identify prognosis factors in Pneumocystis carinii pneumonia at diagnosis and construct a model to predict mortality according to these prognosis factors.

METHODS

Seventy-seven consecutive cases of proven AIDS-related Pneumocystis carinii pneumonia (67 men, 10 women, mean age 37.2 years) were reviewed to determine the most accurate initial prognostic factors and estimate an individual prediction of death. A stepwise logistic regression analysis was performed. Three kinds of data were entered into the logistic model: historical data, clinical and laboratory data obtained within the first 24 hours of diagnosis, and specific data related to chest X-ray and bronchoalveolar lavage results.

RESULTS

The sum of arterial partial pressure of oxygen and carbon dioxide (PaO2 + PaCO2) and serum albumin level best predicted a fatal outcome in multivariate analysis.

CONCLUSION

The logistic equation provided by the model might be used to accurately and quickly identify the patients with severe Pneumocystis carinii pneumonia who might benefit from supportive intensive care.

[Techniques and complications of interventional radiology in vascular diseases of transplanted kidneys]

The authors present a general review on the various techniques of interventional radiology in the treatment of vascular complications of renal transplants. Arterial stenosis require generally percutaneous transluminal angioplasty; arterial stenting is justified in cases of multiple restenosis and occluding dissection. Arterial thrombosis is treated by fibrinolysis or clot aspiration. Treatment of venous complications, such as stenosis or thrombosis, require analogous methods. Arterio-venous fistula and arterial aneurysms due to renal biopsy can be obliterated by dissection with a guide wire, or dropping of metallic coils, or electrical embolization. The authors emphasize the technical aspects, the difficulties and the complications of these procedures. The most frequent complication is the spasm of the renal transplant artery, which may lead to thrombosis. Arterial wall rupture and dissections are very rare. Hematoma at the puncture site of the arterial access are frequent; they may lead to false aneurysm, which can be treated also by noninvasive methods of interventional radiology.

[Absence of mitral valve prolapse during panic attacks induced by sodium lactate]

The recent identification of a new type of anxiety state, panic attack, has drawn attention to common pathways between panic disorder and cardiac somatization, particularly mitral valve collapse. A double-blind study was set up, using doppler-echocardiography during a panic attack induced by sodium lactate infusion. The results showed that there was no relationship between panic attack and mitral valve collapse, and that the lactate infusion-anxiety rate was only 35 percent.

[Viral pneumopathies after heart transplantation. Radioclinical analysis]

From a retrospective study of 80 cases of heart transplantation, the contribution of chest X-rays to the diagnosis of viral pneumonia was studied. Among 66 episodes of pneumonia, a viral cause was proved in 16 cases (CMV: 9, Herpes: 7), with 13 cases during the first 4 months. CMV pneumonia was revealed in 3 cases by a diffuse pulmonary infiltrate with a rapidity fatal outcome and in 6 cases by focal infiltrates that disappeared within 1 and 7 weeks. Herpes pneumonia was immediately revealed, in 5 cases, by a diffuse infiltrate. In 11 out of 16 cases, the viral pneumonia improved but its course was complicated by the development of another pneumonia.

[Imaging of cervical and thoracic chordoma. Apropos of 2 cases]

Chordoma is a rare tumor in spine. Two cases, exceptional in adolescents, are reported. The clinical evolution is slow and progressive. CT shows a lobulated tumor, precises the degree of vertebral osteolysis and detects intra-tumoral calcifications. MRI is useful to determine especially in high in soft tissues and the vertebral canal. Arteriography is realised in pre-operative time and permits an embolization when the tumor is hypervascularised.

Improved subtraction technique in intravenous digital left ventriculography: comparison with radionuclide studies

Adequate processing of left ventricular angiograms depends on the visualisation of all segments of the ventricular wall. At the same time, subtraction of different images can enhance different heart segments but commercially available methods do not allow simultaneous viewing of several images masked by different processes. Using our software, for each studied frame, a four quadrant display permits the simultaneous visualisation of a mask mode image, a diastolic-systolic difference image, an image obtained by subtraction of a frame at the same cycle time and a composite mask subtracted image. The composite mask image is obtained by weighting three images according to videodensitometric measurements by reference to previously acquired data. This method facilitates contour delineation and computation of the ejection fraction by area-length method. Correlation with radionuclide estimates of left ventricular ejection fraction is higher (n = 60, r = 0.90, SEE = 8%) than using the classical mask mode display (n = 60, r = 0.82, SEE = 11%). In a subgroup of 30 patients the contrast medium was injected in an antecubital vein and the correlation coefficient remained satisfactory (n = 30, r = 0.89, SEE = 7%) when compared with the classical subtraction technique (n = 30, r = 0.70, SEE = 12%). We therefore conclude that the composite mask method gives comparatively similar values for left ventricular ejection fraction to those acquired by radionuclide angiography.

[Value of digital subtraction of left ventriculographies by the venous route. Comparison with balanced scintigraphy of the heart cavities]

The development of numerisation material in radiology currently permits to perform usual cardiovascular tests. The authors report a series of 48 patients who benefited from the determination by numerised left ventriculography, of their stroke volume (SV). In 37 cases, the peripheral venous route is used while in 11 cases the central venous route is used, in the pulmonary artery trunk. The SV values obtained with both methods (one advocated by the manufacture and another one developed by the authors), are correlated with the SV values obtained with the isotopic method, used as reference. The correlations are satisfactory, approximately 0.79 for all patients of the study, and markedly improve when the injection of the contrast material is performed in the pulmonary artery (approximately 0.95). The authors conclude that determination of the left ventricle SV by numerisation is an interesting technique in centers where there is no department of nuclear medicine, and is absolutely necessary to complement right catheterisation.